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FROM West Hazmat FAX NO. : 19166388613 Dec. 20 2001 02:29PM P2 <br /> ._.... -- ----- -..._... <br /> aan 1Qagluin County Environmental Health Services, Unit IV Well Pe rrni is ori nt <br /> u 0 � Sir <br /> Jai ADdRE�SS�r , 7 . ih//�'S�{� 6fda RLRMIT S <br /> SToc tt-To d In <br /> LICENSED CONTRACTORS DECLARATIONL(_ CD} <br /> I hereby affirm that I am licensed under the provision;,of Chaptor 9 (commanciny with Section 7000)of Division <br /> 3 of the Business and Professions Code and my tirense is in full force;and eff8ct. <br /> License#f:.----- �._ ..S........._.......... --- Expir'atiun Date:..---Q. _ _O ...... <br /> Data: 2 - Z O ' O Contractor xJC4_4Jdt <br /> Signatur L s vG Title-6earr�l'C .tN'A d <br /> Printed nary* <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of porjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> — I have and will maintain a certificate of consent to self-instue for workers'compensatlon, as providod for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> / <br /> ✓ I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the perform arico of the work for which this permit is issuPd. My workers'cornpensation insurances <br /> carrier and policy numbers are: <br /> Carrier: �/��r�`d _. ..._-..._._ -, ,Policy Number: <br /> ✓I certify that In the performance:of 1ha work for which this permit is issued, i shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if i <br /> should become subject to the workers'compensation provisions of Section 3700 of the LabgLLode, I shall <br /> forthwith comply with thoia provisions. <br /> Date: /2� Zv."o(--Signature. <br /> Printed NanW-� ' <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTERES'r,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I. licensed uuthorized roprosontative),hereby <br /> authorim._ it 00 -SAG O oZ a-,-i CO rJ Arl . <br /> to sign this San Joaquin County Well Permit Application on my behalf_ I understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 5-17-20001 Bill <br /> tin -,n- �snrri,� ur .ar CI'UCfigt?;;RT. bq:LGt 0992/SZ/0I <br />